Coral Keratitis: Case Report and Review of Mechanisms of Action, Clinical Management and Prognosis of Ocular Exposure to Palytoxin

Figures & data

Table 1 Published Case Reports

Paper/Reference #	Case	Year Published	Location	Age/Gender	Type of Contact	presenting VA in Involved Eye	Other History	Clinical Course and Treatment Timeline	BCVA at Follow-Up	Other Systemic Involvement	Medical Management	Surgical Management
Dead man’s finger’ keratoconjunctivitis^Citation17	Numerous	1993	Britain	NS	Ocean water	NS	NS	Moderate conjunctival chemosis, punctate intraepithelial keratopathy, and punctate bulbar and tarsal conjunctival hemorrhages. All patients had complete recovery within 2–14 days.	NS	NS	Topical antibiotics and steroids	None
			Incident in the
			Bahamas, care					Immediate pain, conjunctival injection, and eyelid erythema. Scattered corneal epithelial infiltrates, and
			in the United States					variably sized foreign bodies noted. Topical antibiotics and NSAIDs for several days. Resolution with addition
Red coral keratitis^Citation18	1 of 1	2000		39 F	Ocean water	NS	NS	of steroids, exacerbation once treatment stopped. Sustained resolution with longer course of steroids.	20/20 OU	NS	Topical antibiotics, NSAIDs, and eventual steroids	None
						20/20 with
						deterioration to		Irritation, and redness with pain, eyelid swelling, photophobia, and purulent discharge. Diffuse bilateral			Antibiotics and artificial tears, then topical steroids with oral
						20/60 OD and		punctate epithelial erosions noted the next day. Antibiotics and artificial tears were used for three days. Ring			doxycycline and ascorbic acid. Steroids and therapeutic contact
Aquarium Coral						20/125 OS at three		infiltrate noted at three days OS. Steroids and corneal protective agents started, eventual resolution at 12	20/20 OD, 20/30		lens used to resolve persistent stromal ring. Cyclosporine
Keratoconjunctivitis^Citation5	1 of 2	2010	United States	31 M	NS	days	Contact lens use	weeks but stromal thinning and steepening remained OS.	OS	Bitter metallic taste	continued after resolution of epithelial defect.	None
Aquarium Coral Keratoconjunctivitis^Citation5	2 of 2	2010	United States	49 M	Rubbed right eye	20/25 OD	LASIK OU	Pain, redness, and blurry vision. Conjunctival injection and scattered epithelial punctate erosions.	20/20	NS	Topical steroids and antibiotics	None
Dangerous reef aquaristics:
Palytoxin of a brown encrusting								Immediate burning sensation, then rinsed with tap water. Two and a half hours later develops systemic signs.		Dyspnea, nausea and shivering,
anemone causes toxic corneal								ICU monitoring required. Descemet’s folds noted. Ulceration developed with slow resolution and residual	20/25 OD, 20/20	Tachycardia, elevated WBC and		Amniotic membrane transplant
reactions^Citation7	1 of 1	2015	Switzerland*	63 M	Direct spraying	Finger count OU	NS	astigmatism. Scleral contact lens fitted four months after incident.	OS	LDH, with myoglobinuria	Antibiotic and steroid drops	OU
Unique case of palytoxin-related keratitis^Citation13	1 of 1	2016	United Kingdom*	45 F	Direct spraying	6/5 OS	NS	Immediate pain. Eye irrigation at home. Eyelid swelling, chemosis, injection, diffuse punctate epithelial erosions, and a circumferential marginal ulcer one day later. Steroids started on day two. Residual mild corneal scarring and vascularization.	NS	NS	Antibiotics and lubricants with addition of steroids on day two	None
Corneal Toxicity Associated with Aquarium Coral Palytoxin^Citation11	1 of 7	2017	United States or Canada*	33 M	NS	20/60 OD, 20/40 OS	None	Pain, photophobia and decreased vision OU. Conjunctival injection, and reversible superficial punctate epitheliopathy noted OU.	20/20 OU	NS	Topical steroids, Medrol dose pack	None
Corneal Toxicity Associated with Aquarium Coral Palytoxin^Citation11	2 of 7	2017	United States or Canada*	45 M	NS	Finger count OU	HSV OD	Two days of progression at home before presentation. Corneal edema and Descemet’s folds with peripheral thinning OU. Mild iritis OU. Bilateral corneal melt and perforation occurred over three days.	20/30 OD, 20/40 OS	NS	Topical antibiotics, doxycycline, valacyclovir	bilateral urgent sequential penetrating keratoplasty OS followed by OD ten days later.
Corneal Toxicity Associated with Aquarium Coral Palytoxin^Citation11	3 of 7	2017	United States or Canada*	39 F	NS	20/60 OS	Soft contact lens wear	Foreign body sensation and decreased vision. Conjunctival injection and mild edema noted. Given antibiotics and returned two days later with acuity now at 1/200. Corneal ring infiltrate, and anterior chamber cells seen. Switched to different antibiotic and added NSAID. Further follow-up showed ruptured bullae. Started on steroids with gradual improvement, but inferior corneal scarring and thinning remained. Rigid gas permeable contact lens helped correct final vision.	20/60 OS	NS	Topical antibiotics and NSAIDs with topical and oral steroids and doxycycline started later.	None
Corneal Toxicity Associated with Aquarium Coral Palytoxin^Citation11	4 of 7	2017	United States or Canada*	71 M	NS	20/400 OU	NS	Corneal edema, Descemet’s folds, and large epithelial defects OU. Epithelial hydrops and subepithelial bullae noted. Eventual corneal scarring correctable with hybrid contact lens OD.	20/40 OD, 20/25 OS	NS	Topical antibiotic, oral doxycycline	Penetrating keratoplasty, cataract extraction with IOL OS. Amniotic membrane transplant.
Corneal Toxicity Associated with Aquarium Coral Palytoxin^Citation11	5 of 7	2017	United States or Canada*	42 M	NS	5/200 OS	Soft CL wear	Conjunctival injection, and severe corneal melt within 10 hours. Positive mold culture also noted.	20/100 OS	NS	NS	Deep anterior lamellar patch graft
Corneal Toxicity Associated with Aquarium Coral Palytoxin^Citation11	6 of 7	2017	United States or Canada*	56 M	NS	20/70	NS	Conjunctival injection, paracentral corneal ulcer, thinning/melt. Eventual scarring and persistent reduced corneal sensation.	20/40 OS	NS	Topical antibiotic, doxycycline	Lateral tarsorrhaphy
Corneal Toxicity Associated with Aquarium Coral Palytoxin^Citation11	7 of 7	2017	United States or Canada*	45 M	NS	20/200 OD	NS	Corneal ulceration, melt and perforation.	20/400 OD	NS	Topical antibiotic, daily pressure patching	Amniotic membrane transplant OU, synechiolysis, cataract extraction.
Palytoxin Exposure Causing
Prolonged Conjunctivitis and											Antibiotics, lubricants, and oral opioids. Steroid and phenylephrine
Episcleritis without Corneal								Salt water (ocean) irrigation, antibiotic and lubricant treatment for five days, but pain, photophobia, and			added. Mast cell stabilizing agent and topical NSAIDs added while
Involvement^Citation14	1 of 1	2017	Australia*	35 M	Direct spraying	~20/30	Previously healthy	decreased vision persisted. No corneal involvement. Steroids added with eventual resolution in seven weeks.	> 20/20	NS	steroid tapered.	None
Chemical burns caused by crust anemone^Citation15	1 of 1	2019	Germany	38 M	Direct spraying	20/25	Anxiety, panic attacks	Eye irrigation at home. Exam showed conjunctival chemosis, follicle formation of the bulbar conjunctiva with occasional hemorrhages and immunoprecipitates of the cornea. Improvement within a few days.	NS	Nausea, tachycardia	Steroids, antibiotics, and povidone	None
Toxic corneal reaction due to exposure to palytoxin^Citation12	1 of 1	2019	Spain	22 M	Water from aquarium	<20/60 OD	Monthly replacement CL,	Immediate pain, photophobia, and blurred vision OD. Eye irrigation at home and removal of contact lens. Reinsertion of contact lens with progression of symptoms over one week. Exam showed central ring with immune infiltrate and satellite subepithelial micro infiltrates, Descemet folds, anterior chamber inflammatory reaction. Empiric infectious medications for 72 hours showed no improvement. Steroids started with immediate improvement. Eventual scleral contact lens for visual acuity correction. Residual central fibrosis and paracentral stromal thinning.	20/40 to 20/25 post scleral contact lens	NS	Chlorhexidine, antibiotics, and cyclopentolate. Then switched to topical steroids and artificial tears on demand, with oral doxycycline and ascorbic acid.	Scleral contact lens
Melting corneas after moving a marine aquarium^Citation16	1 of 1	2019	Netherlands	44 M	Rubbed right eye	20/400 OU	NS	Pain and redness OS followed hours later by OD pain and redness. Rinsed with tap water. After four days of antibiotic treatment he had strong hyperemia, mild pus, and edematous turbid corneas. IV antibiotics were started and later oral glucocorticoids. Result was limbal cell failure and conjunctival overgrowth.	20/200	NS	Oral antibiotics, then IV antibiotics. Finally, high dose of oral glucocorticoids with ascorbic acid, ciclosporin eye drops and doxycycline.	None
Current report	1 of 1	2020	United States	37 M	Inoculation with dust previously covering coral	Finger count	Testicular cancer, nephrolithiasis, depression, acid reflux headaches	Two days of progression at home before admission to the hospital. Progressive dyspnea resulted in ICU stay. After discharge the eye was washed. Epithelial erosion with eventual corneal perforation after weeks. Corneal transplant was given to correct perforation.	Finger count	Epigastric abdominal pain, headache, dyspnea, elevated WBC, elevated CRP, pruritis, streaks running up lacerated arm	Steroids, antibiotics, vitamin C, alpha agonists, beta blockers, opioids for pain	Amniotic membrane graft x2, synechiolysis, tarsorrhaphy, penetrating keratoplasty.

Note: *Based on location of publication or corresponding author.

Abbreviations: M, male; F, female; OD, right eye; OS, left eye; OU, both eyes; NS, not specified; CI, contact lens; LDH, lactate dehydrogenase; WBC, white blood cell count; CRP, C-reactive protein.

Figure 1 Right eye of the patient at nearly eighteen months following penetrating keratoplasty. Courtesy of Dr.Ryan T Barrett file photo.

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